MEDICARE: DALTON ROBERT CARROLL FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	220441	LA

General Provider Information

NPI Number	:	1376115212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALTON ROBERT CARROLL FNP-C

Provider Business Mailing Address
First Line	:	625 DUMAINE DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-6277
Country	:	US
Telephone Number	:	318-751-1246
Fax Number	:

Provider Business Practice Location Address
First Line	:	8445 LINE AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-5925
Country	:	US
Telephone Number	:	318-703-5655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	07/12/2021

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